Medical emergencies can happen at any time without any prior notice. During a crisis, you need to be conscious enough to make decisions, such as informing your private medical insurance provider, filling out forms, collecting bills, and so on.

With a TPA, you can avoid all these hassles and concentrate on your or your loved ones’ health. Medical third-party administrators can make this possible by assisting you at every step during critical times. Let us explain them in detail.

What is a Third-Party Administrator in Health Insurance?

TPA in health insurance is an entity that acts as an intermediary between the policyholder and the insurance company. When you file an insurance claim, it is a TPA’s job to assist you at every step of the claim procedure. Most of the time, these third-party administrators work independently, but they can also work with insurers, most probably representing them.

 Role of TPA in Medical Insurance

● Easy Settlement of Claims

The best health insurance providers need all the details to settle claims, and the TPA assists in this process. The hospital directly coordinates with the TPA to ask for pre-authorisation for the insured’s treatment.

The TPA will cross-check whether the policyholder’s submitted documents are enough to process the claim. Moreover, the TPA asks policyholders to provide further information when needed.

●  Issuance of Health Cards

A TPA is responsible for issuing authorised health cards to policyholders and validating the policy’s issuance. The card has all the details of the policyholder and their insurance policy. This card should be shown at the hospital to avail of the cashless hospitalisation benefits.

●  Maintenance of Records

Third-party administrators are also responsible for maintaining documents and keeping all the records carefully.

● Arrange for Value-added Services

A health insurance TPA can help arrange policyholders’ value-added services, such as ambulance facilities, surgeon or specialist references, and wellness programs. The insured may call the TPA to obtain such services that are covered under their insurance policy.

● A strong Network of Empanelled Hospitals

TPAs help insurance companies develop a strong network of empanelled hospitals. The policyholders can check health insurance TPA hospital lists to learn about the TPAs that are partnered with their health insurance companies.

Benefits of TPAs in Health Insurance for the Policyholders

A TPA in health insurance provides several benefits to the policyholder. Some of these are the following:

• Proper guidance on important documentation
• Streamline the cashless claims settlement process
• Provide complete support throughout hospitalisation
• Issue ID cards to the policyholders or patients
• Simplify the claim settlement process
• Offer value-added services for preventive check-ups, second-opinion services, and wellness programs
• Provide 24/7 customer support.

How Does TPA in Health Insurance Work?

For Claim Reimbursement

• When you need hospitalisation services from any hospital, you need to make upfront payments for your treatment.
• Make sure you keep all the medical bills, prescriptions, receipts, and other important documents to give valid proof for raising the claim.
• After inspecting all the submitted documents, the TPA will forward the claim to the insurance company.
• On getting claim approval, the TPA will reimburse the entire amount through a bank transfer.

For Cashless Treatment

• If you want to undergo cashless treatment, you need to be hospitalised at an authorised hospital.
• After this, the TPA in health insurance verifies your eligibility criteria and the policy’s coverage. If everything is fine, the TPA issues a pre-authorisation to the hospital to determine whether the policyholder can avail of hospitalisation services without making an upfront payment.
• Once you get the authorisation from your insurance company, you can receive cashless treatment. The TPA will settle hospital dues on behalf of the insurance company.

How to Cancel TPA in Health Insurance?

• Step 1: Contact your insurance provider via email or phone.
• Step 2: Share your insurance details and unique ID.
• Step 3: Explain the reason for your TPA service cancellation.
• Step 4: After the insurance provider approves your cancellation request, you can choose another TPA from the provided list.

At the End: Is TPA Necessary in Health Insurance?

If you want hassle-free services during the claim procedure, you can opt for TPA services. Although third-party administrators are not mandatory, if you choose to get one, make sure you understand what is TPA in medical insurance and how they can help you.

Moreover, if you are not satisfied with their services, you can opt for cancellation. However, it has a whole different procedure altogether.